National health system characteristics, breast cancer stage at diagnosis, and breast cancer mortality: a population-based analysis

Enhanced treatment of breast cancer brain metastases with oncolytic virus expressing anti-CD47 antibody and temozolomide

Limited therapeutic options are available for patients with breast cancer brain metastases (BCBM), and thus there is an urgent need for novel treatment approaches. We previously engineered an effective oncolytic herpes simplex virus 1 (oHSV) expressing a full-length anti-CD47 monoclonal antibody (mAb) with a human IgG1 scaffold (OV-αCD47-G1) that was used to treat both ovarian cancer and glioblastoma. Here, we demonstrate that the combination of OV-αCD47-G1 and temozolomide (TMZ) improve outcomes in preclinical models of BCBM. The combination of TMZ with OV-αCD47-G1 synergistically increased macrophage phagocytosis against breast tumor cells and led to greater activation of NK cell cytotoxicity. In addition, the combination of OV-αCD47-G1 with TMZ significantly prolonged the survival of tumor-bearing mice when compared with TMZ or OV-αCD47-G1 alone. Combination treatment with the mouse counterpart of OV-αCD47-G1, termed OV-A4-IgG2b, also enhanced mouse macrophage phagocytosis, NK cell cytotoxicity, and survival in an immunocompetent model of mice bearing BCBM compared with TMZ or OV-A4-IgG2b alone. Collectively, these results suggest that OV-αCD47-G1 combined with TMZ should be explored in patients with BCBM.

Radiotherapy resources in the Philippines: A 2022 update

BACKGROUND

Cancer is the third leading cause of death in the Philippines. Radiotherapy (RT) is integral to the treatment and palliation of cancer. Therefore, RT resources across the country must be surveyed and optimized.

METHODS

Online surveys were sent to the heads of all 50 RT facilities in the Philippines. The survey included items regarding the facility itself, personnel, and available services.

FINDINGS

The survey had a 98% response rate. 76% of RT facilities in the Philippines are privately owned; 12 are government/public institutions and 8 are academic centers. Over a third are in the National Capital Region; three regions are without a single RT facility. For a population of >110 million, the Philippines has 53 linear accelerators, 125 radiation oncologists, 56 residents, 114 medical physicists, 113 radiation oncology nurses, and 343 radiation therapists. Nine radiation oncology residency programs are active. All facilities are capable of 3D conformal radiotherapy, and 96% are capable of intensity modulated radiotherapy. <30% offer stereotactic radiotherapy, and <50% offer HDR brachytherapy.

CONCLUSION

While there has been significant expansion of RT resources over the years, RT remains inaccessible for many in the Philippines. Urgent investment in training and retaining RT personnel is needed as well. Policy summary: With its current cancer burden, the Philippines needs at least 170 linear accelerators, 300 radiation oncologists, and 150 medical physicists. Public/government cancer centers must be built, with priority given to regions without RT facilities. HDR brachytherapy and stereotactic radiotherapy services must also be expanded. A national RT task force must be created to ensure the quality, availability, and accessibility of RT in the Philippines. Further work exploring payment schemes that improve access to RT and mitigate financial toxicity is needed, as well as integration of radiation oncology providers and health policy experts into national health system decision making.

National age-specific mortality trends for cervical and breast cancers in urban-rural areas of China from 2009 to 2021: a population-based analysis

BACKGROUND

Cervical and breast cancers are among the top 4 leading causes of cancer-related mortality in women. This study aimed to examine age-specific temporal trends in mortality for cervical and breast cancers in urban and rural areas of China from 2009 to 2021.

METHODS

Age-specific mortality data for cervical and breast cancers among Chinese women aged 20-84 years were obtained from China's National Disease Surveillance Points system spanning the years 2009 to 2021. Negative binomial regression models were utilized to assess urban-rural differences in mortality rate ratios, while Joinpoint models with estimated average annual percent changes (AAPC) and slopes were employed to compare temporal trends and the acceleration of mortality rates within different age groups.

RESULTS

From 2009 to 2021, there was a relative increase in age-specific mortality associated with the two cancers observed in rural areas compared with urban areas. A rising trend in the screening age of 35-64 [AAPC: 4.0%, 95% confidence interval (CI) 0.5-7.6%, P = 0.026] for cervical cancer was noted in rural areas, while a stable trend (AAPC: - 0.7%, 95% CI - 5.8 to 4.6%, P = 0.78) was observed in urban areas. As for breast cancer, a stable trend (AAPC: 0.3%, 95% CI - 0.3 to 0.9%, P = 0.28) was observed in rural areas compared to a decreasing trend (AAPC: - 2.7%, 95% CI - 4.6 to - 0.7%, P = 0.007) in urban areas. Urban-rural differences in mortality rates increased over time for cervical cancer but decreased for breast cancer. Mortality trends for both cervical and breast cancers showed an increase with age across 4 segments, with the most significant surge in mortality observed among the 35-54 age group across urban and rural areas, periods, and regions in China.

CONCLUSIONS

Special attention should be given to women aged 35-54 years due to mortality trends and rural-urban disparities. Focusing on vulnerable age groups and addressing rural-urban differences in the delivery of cancer control programs can enhance resource efficiency and promote health equity.

Influence of Breast Cancer Awareness Month on Public Interest of Breast Cancer in High-Income Countries Between 2012 and 2022: Google Trends Analysis

BACKGROUND

Breast cancer is the most common cancer among women worldwide. High-income countries have a greater incidence and mortality rate of breast cancer than low-income countries. As a result, raising awareness about breast cancer is crucial in increasing the chances of early detection and treatment. Social media has evolved into an essential tool for Breast Cancer Awareness Month campaigns, allowing people to share their breast cancer stories and experiences while also providing a venue for education and support.

OBJECTIVE

The aim of this study was to assess the level of public interest in searches linked to breast cancer among a sample of high-income nations with a sizable internet user base from 2012 to 2022. We also sought to compare the proportional search volume for breast cancer during Breast Cancer Awareness Month with that during other months of the year.

METHODS

Google Trends was used to retrieve data on internet user search behaviors in the context of breast cancer from 2012 to 2022. Seven countries were evaluated in this study: Australia, Canada, Ireland, New Zealand, the United Kingdom, Saudi Arabia, and the United States, in addition to global data. Breast cancer relative search volume trends were analyzed annually, monthly, and weekly from 2012 to 2022. The annual percent change (APC) was calculated for each country and worldwide. Monthly and weekly data were used to identify potential trends.

RESULTS

A fluctuating pattern in APC rates was observed, with a notable increase in 2018 and a significant decrease in 2020, particularly in Saudi Arabia. Monthly analysis revealed a consistent peak in search volume during October (Breast Cancer Awareness Month) each year. Weekly trends over a 20-year period indicated significant decreases in Australia, Canada, New Zealand, and the United States, while increases were noted in Ireland. Heatmap analysis further highlighted a consistent elevation in median search volume during October across all countries.

CONCLUSIONS

These findings underscore the impact of Breast Cancer Awareness Month and suggest potential influences of governmental COVID-19 pandemic control measures in 2020 on internet search behavior.

Socioeconomic characteristics, cancer mortality, and universal health coverage: A global analysis

BACKGROUND

Achieving universal health coverage (UHC) involves all individuals attaining accessible health interventions at an affordable cost. We examined current patterns and temporal trends of cancer mortality and UHC across sociodemographic index (SDI) settings, and quantified these association.

METHODS

We used data from the Global Burden of Disease Study 2019 and Our World in Data. The UHC effective coverage index was obtained to assess the potential population health gains delivered by health systems. The estimated annual percentage change (EAPC) with a 95% confidence interval (CI) was calculated to quantify the trend of cancer age-standardized mortality rate (ASMR). A generalized linear model was applied to estimate the association between ASMR and UHC.

FINDINGS

The high (EAPC = -0.9% [95% CI, -1.0%, -0.9%]) and high-middle (-0.9% [-1.0%, -0.8%]) SDI regions had the fastest decline in ASMR (per 100,000) for total cancers from 1990 to 2019. The overall UHC effective coverage index increased by 27.9% in the high-SDI quintile to 62.2% in the low-SDI quintile. A negative association was observed between ASMR for all-cancer (adjusted odds ratio [OR] = 0.87 [0.76, 0.99]), stomach (0.73 [0.56, 0.95]), breast (0.64 [0.52, 0.79]), cervical (0.42 [0.30, 0.60]), lip and oral cavity (0.55 [0.40, 0.75]), and nasopharynx (0.42 [0.26, 0.68]) cancers and high UHC level (the lowest as the reference).

CONCLUSIONS

Our findings strengthen the evidence base for achieving UHC to improve cancer outcomes.

FUNDING

This work is funded by the China National Natural Science Foundation and Chinese Academy of Medical Sciences Innovation Fund for Medical Science.

Virtual Reality Simulation-Based Training in Image-Guided Breast Intervention in Low- and Middle-Income Countries

Online education has revolutionized global radiology education for low- and middle-income countries (LMICs). However, procedures requiring hands-on training, such as breast biopsies, are primarily taught through in-person sessions and patient interaction. Virtual reality (VR) offers an immersive way to simulate these sessions remotely. This Viewpoint presents an experience with an ultrasound-guided breast biopsy VR platform that may allow radiology residents in LMICs to practice breast interventions and provide all trainees with shared procedural experiences.

Extracellular volume measured by whole body CT scans predicts chronic cardiotoxicity in breast cancer patients treated with neoadjuvant therapies based on anthracyclines: A retrospective study

INTRODUCTION

Neoadjuvant chemotherapies for breast cancer (BC) are effective but potentially cardiotoxic, and expose long survivors at risk of chemotherapy-related cardiac dysfunction (CTRCD). Unfortunately, early screening for CTRCD has actual diagnostic limits. Myocardial extracellular volume (mECV) is a radiological marker used in cardiac CT scans and cardiac magnetic resonance for diagnosis and follow-up of CTRCD. It can be measured in whole-body CT (WB-CT) scan, routinely performed in patients at high risk of relapse, to evaluate CTRCD occurrence during oncological follow-up.

METHODS

82 WB-CT scans were examined at baseline (T0) and during oncological follow-up at first year (T1) and fifth year (T5) after the end of neoadjuvant treatment. mECV was measured at 1 min (PP) and 5 min (DP) after contrast injection. 31 echocardiograms were retrieved in T1 to perform a linear correlation between mECV and left ventricular ejection fraction (LVEF).

RESULTS

mECV values in T0 were similar between the two groups both in PP and in DP. Significant results were found for PP values in T1 (37.0 % vs 32 %, p = 0.0005) and in T5 (27.2 % vs 31.2 %, p = 0.025). A cut-off value of 35 % in PP proved significant in T1 (OR = 12.4, p = 0.004), while mECV was inversely correlated with LVEF both in PP (adj-S = -3.54, adj-p = 0.002) and in DP (adj-S = -2.51, adj-p = 0.0002), suggesting a synergistic action with the age at diagnosis (p < 0.0001, respectively).

CONCLUSIONS

WB-CT scans performed during oncological reassessment in patients at high-risk of recurrence could be used for CTRCD screening in cardiovascular low-risk patients, especially in aging patients with mECV values above 35 %.

Advancements in Understanding the Hide-and-Seek Strategy of Hibernating Breast Cancer Cells and Their Implications in Oncology from a Broader Perspective: A Comprehensive Overview

Despite recent advancements in technology, breast cancer still poses a significant threat, often resulting in fatal consequences. While early detection and treatments have shown some promise, many breast cancer patients continue to struggle with the persistent fear of the disease returning. This fear is valid, as breast cancer cells can lay dormant for years before remerging, evading traditional treatments like a game of hide and seek. The biology of these dormant breast cancer cells presents a crucial yet poorly understood challenge in clinical settings. In this review, we aim to explore the mysterious world of dormant breast cancer cells and their significant impact on patient outcomes and prognosis. We shed light on the elusive role of the G9a enzyme and many other epigenetic factors in breast cancer recurrence, highlighting its potential as a target for eliminating dormant cancer cells and preventing disease relapse. Through this comprehensive review, we not only emphasise the urgency of unravelling the dynamics of dormant breast cancer cells to improve patient outcomes and advance personalised oncology but also provide a guide for fellow researchers. By clearly outlining the clinical and research gaps surrounding dormant breast cancer cells from a molecular perspective, we aim to inspire further exploration of this critical area, ultimately leading to improved patient care and treatment strategies.

Growing the global cancer care system: success stories from around the world and lessons for the future

Despite major biomedical advancements in various realms of oncology, the benefits of these developments are not equitably distributed, particularly in underresourced settings. Although much work has described the challenges and systemic barriers in global cancer control, in this article we focus on success stories. This article describes clinical care delivered at Rwanda's Butaro Cancer Center of Excellence, the cancer research collaborations under India's National Cancer Grid, and the efforts of Latin America's Institute of Cancer of São Paulo in advancing cancer care and training. These examples highlight the potential of strategic collaborations and resource allocation strategies in improving cancer care globally. We emphasize the critical role of partnerships between physicians and allied health professionals, funders, and policy makers in enhancing access to treatment and infrastructure, advancing contextualized research and national guidelines, and establishing regional and global collaborations. We also draw attention to challenges faced in diverse global settings and outline benchmarks to measure success in the fight against cancer.

Using Patient Navigation to Reduce Time to Diagnosis of Breast Cancer in Uganda

PURPOSE

The Ugandan Ministry of Health adopted BI-RADS as standard of care in 2016. The authors performed a medical audit of breast ultrasound practices at four tertiary-level hospitals to assess interpretive performance. The authors also determined the effect of a low-cost navigation program linking breast imaging and pathology on the percentage of patients completing diagnostic care.

METHODS

The authors retrieved 966 consecutive diagnostic breast ultrasound reports, with complete data, for studies performed on women aged >18 years presenting with symptoms of breast cancer between 2018 and 2020 from participating hospitals. Ultrasound results were linked to tumor registries and patient follow-up. A medical audit was performed according to the ACR's BI-RADS Atlas, fifth edition, and results were compared with those of a prior audit performed in 2013. At Mulago Hospital, an intervention was piloted on the basis of patient navigation, cost sharing, and same-day imaging, tissue sampling, and pathology.

RESULTS

In total, 888 breast ultrasound examinations (91.9%) were eligible for inclusion. Compared with 2013, the postintervention cancer detection rate increased from 38 to 148.7 cancers per 1,000 examinations, positive predictive value 2 from 29.6% to 48.9%, and positive predictive value 3 from 62.7% to 79.9%. Specificity decreased from 90.5% to 87.7% and sensitivity from 92.3% to 81.1%. The mean time from tissue sampling to receipt of a diagnosis decreased from 60 to 7 days. The intervention increased the percentage of patients completing diagnostic care from 0% to 100%.

CONCLUSIONS

Efforts to establish a culture of continuous quality improvement in breast ultrasound require robust data collection that links imaging results to pathology and patient follow-up. Interpretive performance met BI-RADS benchmarks for palpable masses, except sensitivity. This resource-appropriate strategy linking imaging, tissue sampling, and pathology interpretation decreased time to diagnosis and rates of loss to follow-up and improved the precision of the audit.

Building Radiology Equity: Themes from the 2023 RAD-AID Conference on International Radiology and Global Health

Low- and middle-income countries are significantly impacted by the global scarcity of medical imaging services. Medical imaging is an essential component for diagnosis and guided treatment, which is needed to meet the current challenges of increasing chronic diseases and preparedness for acute-care response. We present some key themes essential for improving global health equity, which were discussed at the 2023 RAD-AID Conference on International Radiology and Global Health. They include (1) capacity building, (2) artificial intelligence, (3) community-based patient navigation, (4) organizational design for multidisciplinary global health strategy, (5) implementation science, and (6) innovation. Although not exhaustive, these themes should be considered influential as we guide and expand global health radiology programs in low- and middle-income countries in the coming years.

Cancer Care Disparities: Overcoming Barriers to Cancer Control in Low- and Middle-Income Countries

The rising global burden of cancer disproportionately affects low- and middle-income countries (LMICs), which account for over half of new patients and cancer deaths worldwide. However, LMIC health systems face profound challenges in implementing comprehensive cancer control programs because of limited health care resources and infrastructure. This analytical review explores contemporary evidence on barriers undermining cancer control efforts in resource-constrained LMIC settings. We conducted a comprehensive literature review of peer-reviewed evidence on cancer control challenges and solutions tailored to resource-limited settings. We provide a conceptual framework categorizing these barriers across the cancer care continuum, from raising public awareness to palliative care. We also appraise evidence-based strategies proposed to overcome identified obstacles to cancer control in the published literature, including task-shifting to nonspecialist health workers, strategic prioritization of high-impact interventions, regional collaborations, patient navigation systems, and novel financing mechanisms. Developing strong primary care delivery platforms integrated with specialized oncology care, alongside flexible and resilient health system models tailored to local contexts, will be critical to curb the rising tide of cancer in resource-limited settings. Urgent global commitments and investments are needed to dismantle barriers and expand access to prevention, early detection, diagnosis, treatment, and palliation services for all patients with cancer residing in LMICs as an ethical imperative. The review elucidates priority areas for policy actions, health systems strengthening, and future research to guide international efforts toward more equitable cancer control globally.

Late-stage diagnosis: The driving force behind high breast cancer mortality in Ethiopia: A systematic review and meta-analysis

INTRODUCTION

Breast cancer continues to be the most common malignancy and the leading cause of cancer-related deaths in Ethiopia. The poor prognosis and high mortality rate of breast cancer patients in the country are largely caused by late-stage diagnosis. Hence, understanding the epidemiology of late-stage diagnosis is essential to address this important problem. However, previous reports in Ethiopia indicated inconsistent findings. Therefore, this literature review was conducted to generate dependable evidence by summarizing the prevalence and determinants of late-stage diagnosis among breast cancer patients in Ethiopia.

METHODS

Pertinent articles were retrieved by systematically searching on major electronic databases and gray literature. Data were extracted into an Excel spreadsheet and analyzed using the STATA 17 statistical software. The pooled estimates were summarized using the random effect meta-analysis model. Heterogeneity and small study effect were evaluated using the I2 statistics and Egger's regression test in conjunction with the funnel plot, respectively. Meta-regression, sub-group analysis, and sensitivity analysis were also employed. Protocol registration number: CRD42024496237.

RESULTS

The pooled prevalence of late-stage diagnosis after combining reports of 24 studies with 8,677 participants was 65.85 (95% CI: 58.38, 73.32). Residence (adjusted OR: 1.92; 95% CI: 1.45, 2.53), patient delay at their first presentation (adjusted OR: 2.65; 95% CI: 1.56, 4.49), traditional medicine use (adjusted OR: 2.54; 95% CI: 1.89, 3.41), and breast self-examination practice (adjusted OR: 0.28; 95% CI: 0.09, 0.88) were significant determinants of late-stage diagnosis.

CONCLUSION

Two-thirds of breast cancer patients in Ethiopia were diagnosed at an advanced stage. Residence, delay in the first presentation, traditional medicine use, and breast self-examination practice were significantly associated with late-stage diagnosis. Public education about breast cancer and its early detection techniques is crucial to reduce mortality and improve the survival of patients. Besides, improving access to cancer screening services is useful to tackle the disease at its curable stages.

An ultra-sensitive and rapid immunosensor for the onsite detection of circulating tumor DNA in breast cancer

Breast cancer currently stands as the most prevalent form of cancer worldwide and the primary cause of cancer-related deaths among women. However, the current diagnostic methods for breast cancer exhibit several limitations, including invasiveness, high costs, and limited sensitivity and specificity. The detection of the PIK3CA-H1047R variant is of paramount importance due to its close association with tumor growth and treatment resistance. Consequently, developing a straightforward, rapid, and highly sensitive approach for detecting PIK3CA-H1047R is of utmost importance. We have been working on the development of a rapid and ultrasensitive biosensor, leveraging the alternating current (AC) electrokinetic (ACEK) capacitive sensing method. This biosensor involves modifying the surface of interdigital electrodes with antibodies, facilitating the antibody-antigen-binding process through AC electrokinetic techniques. Our sensor strategy directly measures the interface capacitance, and the rate of change serves as a quantitative marker for event identification. Remarkably, our biosensor successfully detects the PIK3CA-H1047R antigen within a concentration range of 1 ng/mL to 1 μg/mL. In conclusion, this study proposes a fast and highly sensitive biosensor for the detection of a key breast cancer marker, the PIK3CA-H1047R variant. This technology is expected to improve breast cancer diagnosis, address the limitations of current methods, and provide patients with better treatment options. This detection method offers a promising avenue for on-site and real-time sensitive detection of the PIK3CA-H1047R antigen, potentially revolutionizing breast cancer diagnosis.

Breast Cancer in Women in Gaza: A Review of Clinical Characteristics and Short-Term Survival

PURPOSE

To understand how breast cancer is diagnosed in Gaza, and disease stage distribution, treatment, and survival.

MATERIALS AND METHODS

A clinical record case series study of women diagnosed in 2017 and 2018 was conducted with follow-up until December 31, 2020. Breast cancer crude incidence rates and age-specific incidence rates were calculated. Clinical characteristics, including investigation, diagnosis, and treatment methods by year of diagnosis, were compared using the chi-square test. The 2-year cumulative risk of death from any cause was estimated using the Kaplan-Meier method, and univariate and multivariate Cox proportional hazard regressions estimated hazard ratios and their 95% CIs.

RESULTS

Five hundred twenty-four new diagnoses (mean age, 53 years; range, 23-100) were recorded, giving a crude annual incidence rate of 27 per 100,000 population. Six percent (32/524) were diagnosed at stage I, 35% (185/524) at stage II, 33% (171/524) at stage III, and 19% (99/524) at stage IV. More than one half (52%, 271/524) underwent modified radical mastectomy. Seventy-seven percent (405/524) received chemotherapy, 70% (368/524) hormone therapy, and 39% (204/524) radiotherapy. Data on key prognostic factors were mostly available-stage (93%), estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2; 82%), tumor grade (77%), and tumor size (70%). The overall survival was 95.4% at 1 year and 86.6% at 2 years.

CONCLUSION

Women with breast cancer in Gaza have a high short-term survival after diagnosis. However, one half were diagnosed with advanced disease, and their investigations were incomplete. Better reporting on family history, tumor grade, size, and ER, PR, and HER2 receptor status is needed for future studies.

Development of a model to predict the age at breast cancer diagnosis in a global population

Knowing the mean age at diagnosis of breast cancer (BC) in a country is important for setting up an efficient BC screening program. The aim of this study was to develop and validate a model to predict the mean age at diagnosis of BC at the country level. To develop the model, we used the CI5plus database from the IARC, which contains incidence data for 122 selected populations for a minimum of 15 consecutive years from 1993 to 2012 and data from the World Bank. The standard model was fitted with a generalized linear model with the age of the population, growth domestic product per capita (GDPPC) and fertility rate as fixed effects and continent as a random effect. The model was validated in registries of the Cancer Incidence in Five Continents that are not included in the CI5plus database (1st validation set: 1950-2012) and in the most recently released volume (2nd validation set: 2013-2017). The intercept of the model was 30.9 (27.8-34.1), and the regression coefficients for population age, GDPPC and fertility rate were 0.55 (95% CI: 0.53-0.58, p < 0.001), 0.46 (95% CI: 0.26-0.67, p < 0.001) and 1.62 (95% CI: 1.42-1.88, p < 0.001), respectively. The marginal R2 and conditional R2 were 0.22 and 0.81, respectively, suggesting that 81% percent of the variance in the mean age at diagnosis of BC was explained by the variance in population age, GDPPC and fertility rate through linear relationships. The model was highly accurate, as the correlations between the predicted age from the model and the observed mean age at diagnosis of BC were 0.64 and 0.89, respectively, and the mean relative error percentage errors were 5.2 and 3.1% for the 1st and 2nd validation sets, respectively. We developed a robust model based on population age and continent to predict the mean age at diagnosis of BC in populations. This tool could be used to implement BC screening in countries without prevention programs.

Understanding breast cancer patient pathways and their impact on survival in Mexico

BACKGROUND

Understanding patient pathways from discovery of breast symptoms to treatment start can aid in identifying ways to improve access to timely cancer care. This study aimed to describe the patient pathways experienced by uninsured women from detection to treatment initiation for breast cancer in Mexico City and estimate the potential impact of earlier treatment on patient survival.

METHODS

We used process mining, a data analytics technique, to create maps of the patient pathways. We then compared the waiting times and pathways between patients who initially consulted a private service versus those who sought care at a public health service. Finally, we conducted scenario modelling to estimate the impact of early diagnosis and treatment on patient survival.

RESULTS

Our study revealed a common pathway followed by breast cancer patients treated at the two largest public cancer centres in Mexico City. However, patients who initially sought care in private clinics experienced shorter mean wait times for their first medical consultation (66 vs 88 days), and diagnostic confirmation of cancer (57 vs 71 days) compared to those who initially utilized public clinics. Our scenario modelling indicated that improving early diagnosis to achieve at least 60% of patients starting treatment at early stages could increase mean patient survival by up to two years.

CONCLUSION

Our study highlights the potential of process mining to inform healthcare policy for improvement of breast cancer care in Mexico. Also, our findings indicate that reducing diagnostic and treatment intervals for breast cancer patients could result in substantially better patient outcomes.

POLICY SUMMARY

This study revealed significant differences in time intervals along the pathways of women with breast cancer according to the type of health service first consulted by the patients: whether public primary care clinics or private doctors. Policies directed to reduce these inequities in access to timely cancer care are desperately needed to reduce socioeconomic disparities in breast cancer survival.

Socioeconomic Deprivation and Invasive Breast Cancer Incidence by Stage at Diagnosis: A Possible Explanation to the Breast Cancer Social Paradox

In this study, we assessed the influence of area-based socioeconomic deprivation on the incidence of invasive breast cancer (BC) in France, according to stage at diagnosis. All women from six mainland French departments, aged 15+ years, and diagnosed with a primary invasive breast carcinoma between 2008 and 2015 were included (n = 33,298). Area-based socioeconomic deprivation was determined using the French version of the European Deprivation Index. Age-standardized incidence rates (ASIR) by socioeconomic deprivation and stage at diagnosis were compared estimating incidence rate ratios (IRRs) adjusted for age at diagnosis and rurality of residence. Compared to the most affluent areas, significantly lower IRRs were found in the most deprived areas for all-stages (0.85, 95% CI 0.81-0.89), stage I (0.77, 95% CI 0.72-0.82), and stage II (0.84, 95% CI 0.78-0.90). On the contrary, for stages III-IV, significantly higher IRRs (1.18, 95% CI 1.08-1.29) were found in the most deprived areas. These findings provide a possible explanation to similar or higher mortality rates, despite overall lower incidence rates, observed in women living in more deprived areas when compared to their affluent counterparts. Socioeconomic inequalities in access to healthcare services, including screening, could be plausible explanations for this phenomenon, underlying the need for further research.

Cellular and Exosomal MicroRNAs: Emerging Clinical Relevance as Targets for Breast Cancer Diagnosis and Prognosis

Breast cancer accounts for the highest cancer cases globally, with 12% of occurrences progressing to metastatic breast cancer with a low survival rate and limited effective early intervention strategies augmented by late diagnosis. Moreover, a low concentration of prognostic and predictive markers hinders disease monitoring. Circulating and exosomal microRNAs (miRNAs) have recently shown a considerable interplay in breast cancer, standing out as effective diagnostic and prognostic markers. The primary functions are as gene regulatory agents at the genetic and epigenetic levels. An array of dysregulated miRNAs stimulates cancer-promoting mechanisms, activating oncogenes and controlling tumor-suppressing genes and mechanisms. Exosomes are vastly studied extracellular vesicles, carrying, and transporting cargo, including noncoding RNAs with premier roles in oncogenesis. Translocation of miRNAs from the circulation to exosomes, with RNA-binding proteins in stress-induced conditions, has shown significant cooperation in function to promote breast cancer. This review examines cellular and exosomal miRNA biogenesis and loading, the clinical implications of their dysregulation, their function in diagnosis, prognosis, and prediction of breast cancer, and in regulating cancer signaling pathways. The influence of cellular and exosomal miRNAs presents clinical significance on breast cancer diagnosis, subtyping, staging, prediction, and disease monitoring during treatment, hence a potent marker for breast cancer.

There is no such a thing as a 'biological' basis for cancer disparities: A call to end misreporting of the ultimate determinants of health outcomes

Improved strategies of cancer prevention and control have resulted in tangible benefits for patients with cancer. Disparities in outcome have been reported as a result of inequal access to health care. Historically, differences in health outcomes at population level have been reported according to key characteristics, including race, ethnicity and, more recently, ancestry. These population descriptors have been used to display the differences in the outcome and highlight actionable areas of health disparities, through policy and population health interventions. Yet, they have been commonly mis-intended as ultimate determinants of health outcomes, as recapitulating intrinsic biological differences. A plethora of past literature has described "biological" differences in patients belonging to a specific racial, ethnical or ancestral group, with certain cancers - commonly overlooking the social and economic contextures. The attention has ultimately focused on the existence of intrinsic differences and biological reasons, as opposed to social and economic determinants of disparities in the outcome in disadvantaged or excluded communities, thus nurturing double stigma. In our editorial, we evaluate some key roots of racial attitudes in displaying patient outcomes in oncology epidemiological studies, and call to report ultimate determinants of health - that are, primarily social and economic determinants.

A novel nanoprobe for visually investigating the controversial role of miRNA-34a as an oncogene or tumor suppressor in cancer cells

MiRNA-targeted therapy has become a hot topic in current cancer research. The key to this treatment strategy is to clarify the specific role of miRNA in cancer. However, the roles of some miRNAs acting as oncogenic or tumor suppressors are still controversial, which are influenced by different tumor types, even in the same cancer type. Hence, we designed a novel fluorescent nanoprobe based on polydopamine nanoparticles (PDA NPs) for simultaneously detecting caspase-3 and miRNA-34a within living cells. The specific role of miRNA-34a in different cancer cells could be further identified by studying the expression alterations of caspase-3 and miRNA-34a. Confocal imaging indicated that miRNA-34a indeed acted as a tumor suppressor in anticancer drug-treated MCF-7 and HeLa cells, where the effect of miRNA-34a remains controversial. The designed nanoprobe can offer a promising approach to ascertain the oncogenic or tumor-suppressing role of miRNA in different cancer cells with a simple visualization method, which has valuable implications for exploring the practicability of precision therapy focused on miRNA and evaluating the efficacy of new miRNA-targeted anticancer medications.

Advanced Breast Cancer Care: The Current Situation and Global Disparities

OBJECTIVES

Advanced breast cancer (ABC) is an incurable disease. The number of people living with ABC has increased globally. Disparities in ABC care exist at both individual and system levels. ABC cases in most low- and middle-income countries (LMICs) are underreported due to a lack of national cancer registries. Harmonized guidelines for resource stratification and capacity building in LMICs are under way.

DATA SOURCES

MEDLINE, Cochrane, and Google Scholar databases were used.

CONCLUSION

To improve ABC outcomes and resolve disparities, more robust health systems or pathways need to be developed across the cancer continuum in addition to social education.

IMPLICATIONS FOR NURSING PRACTICE

So far, the ABC specialist nurse role has been variable globally, and to conquer such variability, an international online nurse education and training program is in practice.

The Impact of Medicaid Expansion Under the Affordable Care Act on the Gap Between American Indians and Whites in Breast Cancer Management and Prognosis

BACKGROUND

Breast cancer (BC) death rates in the USA have not significantly declined for American Indians (AIs) in comparison to Whites. Our objective was to determine whether Medicaid Expansion as part of the Affordable Care Act led to improved BC outcomes for AIs relative to Whites.

PATIENTS AND METHODS

Using the National Cancer Database, we conducted a retrospective cohort study. Included were BC patients who were AI and White; 40 to 64 years of age; diagnosed in 2009 to 2016; lived in states that expanded Medicaid in January 2014, and states that did not expand Medicaid. Our outcomes were stage at diagnosis, insurance status, timely treatment, and 3-year mortality.

RESULTS

There were 359,484 newly diagnosed BC patients, 99.49% White, 0.51% AI. Uninsured rates declined more in the expansion states than in the nonexpansion states (OR = 0.44, 95% CI: 0.15-0.97, P < 0.001). Lower rates of Stage I BC diagnosis was found in AIs compared to Whites (46.58% vs. 55.33%, P < .001); these differential rates did not change after Medicaid expansion. Rates of definitive treatment initiation within 30 days of diagnosis declined after Medicaid expansion (P < .001); there was a smaller decline in the expansion states (OR 1.118, 95% CI: 1.09, 1.15, P < .001). Three year mortality was not different between expansion and nonexpansion states post Medicaid expansion.

CONCLUSIONS

In newly diagnosed BCs, uninsured rates declined more in the states that expanded Medicaid in January 2014. Timely treatment post Medicaid expansion declined less in states that expanded Medicaid. There was no differential benefit of Medicaid expansion in the 2 races.

Cell-cell communication characteristics in breast cancer metastasis

Breast cancer, a highly fatal disease due to its tendency to metastasize, is the most prevalent form of malignant tumors among women worldwide. Numerous studies indicate that breast cancer exhibits a unique predilection for metastasis to specific organs including the bone, liver, lung, and brain. However, different types of, The understanding of the heterogeneity of metastatic breast cancer has notably improved with the recent advances in high-throughput sequencing techniques. Focusing on the modification in the microenvironment of the metastatic organs and the crosstalk between tumor cells and in situ cells, noteworthy research points include the identification of two distinct modes of tumor growth in bone metastases, the influence of type II pneumocyte on lung metastases, the paradoxical role of Kupffer cells in liver metastases, and the breakthrough of the blood-brain barrier (BBB) breach in brain metastases. Overall, this review provides a comprehensive overview of the characteristics of breast cancer metastases, shedding light on the pivotal roles of immune and resident cells in the development of distinct metastatic foci.

Feasibility of monitoring Global Breast Cancer Initiative Framework key performance indicators in 21 Asian National Cancer Centers Alliance member countries

Background

The Global Breast Cancer Initiative (GBCI) Framework, launched by the World Health Organisation (WHO) in 2023, emphasises assessing, strengthening, and scaling up services for the early detection and management of breast cancer. This study aims to determine the feasibility of monitoring the status of breast cancer control in the 21 Asian National Cancer Centers Alliance (ANCCA) countries based on the three GBCI Framework key performance indicators (KPIs): stage at diagnosis, time to diagnosis, and treatment completion.

Methods

We reviewed published literature on breast cancer control among 21 ANCCA countries from May to July 2023 to establish data availability and compiled the latest descriptive statistics and sources of the indicators using a standardised data collection form. We performed bivariate Pearson's correlation analysis to measure the strength of correlation between stage at diagnosis, mortality and survival rates, and universal health coverage.

Findings

Only 12 (57%) ANCCA member countries published national cancer registry reports on breast cancer age-standardised incidence rate (ASIR) and age-standardised mortality rate (ASMR). Indonesia, Myanmar, and Nepal had provincial data and others relied on WHO's Global Cancer Observatory (GLOBOCAN) estimates. GLOBOCAN data differed from the reported national statistics by 5-10% in Bhutan, Indonesia, Iran, the Republic of Korea, Singapore, and Thailand and >10% in China, India, Malaysia, Mongolia, and Sri Lanka. The proportion of patients diagnosed in stages I and II strongly correlated with the five-year survival rate and with the universal health coverage (UHC) index. Three countries (14%) reported national data with >60% of invasive breast cancer patients diagnosed at stages I and II, and a five-year survival rate of >80%. Over 60% of the ANCCA countries had no published national data on breast cancer staging, the time interval from presentation to diagnosis, and diagnosis to treatment. Five (24%) countries reported data on treatment completion. The definition of delayed diagnosis and treatment completion varied across countries.

Interpretation

GBCI's Pillar 1 KPI correlates strongly with five-year survival rate and with the UHC index. Most ANCCA countries lacked national data on cancer staging, timely diagnosis, and treatment completion KPIs. While institutional-level data were available in some countries, they may not represent the nationwide status. Strengthening cancer surveillance is crucial for effective breast cancer control. The GBCI Framework indicators warrant more detailed definitions for standardised data collection. Surrogate indicators which are measurable and manageable in country-specific settings, could be considered for monitoring GBCI indicators. Ensuring UHC and addressing health inequalities are essential to early diagnosis and treatment of breast cancer.

Funding

Funding for this research article's processing fee (APC) will be provided by the affiliated institution to support the open-access publication of this work. The funding body is not involved in the study design; collection, management, analysis and interpretation of data; or the decision to submit for publication. The funding body will be informed of any planned publications, and documentation provided.

Bruceine D suppresses CAF-promoted TNBC metastasis under TNF-α stimulation by inhibiting Notch1-Jagged1/NF-κB(p65) signaling

BACKGROUND

Triple-negative breast cancer (TNBC) has a poor prognosis because of its high degree of malignancy and the lack of effective treatment options. Cancer-associated fibroblasts (CAFs) comprise the most abundant stromal cells in the tumor microenvironment (TME), leading to functional impairments and facilitating tumor metastasis. Excessive TNF-α further promotes cross-talk between different cells in TME. Therefore, there is an urgent need to develop more effective therapies and potential drugs that target the key factors that promote TNBC metastasis.

PURPOSE

The study aimed to evaluate the efficacy of Bruceine D, an active compound derived from the Chinese herb Brucea javanica, in inhibiting metastasis and elucidate the underlying mechanism of action in TNBC.

METHODS

In vitro, the clonogenic and the Transwell assays were used to assess the effects of Bruceine D on the proliferation, migration and invasion abilities of co-cultured CAFs and MDA-MB-231 (4T1) cells under TNF-α stimulation. TNF-α, IL-6, CXCL12, TGF-β1, and MMP9 levels in the supernatant of co-cultured cells were determined using ELISA. Western blotting was utilized to detect the expression levels of proteins related to the Notch1-Jagged1/NF-κB(p65) pathway. In vivo, the anti-tumor growth and anti-metastatic effectiveness of Bruceine D was evaluated by determining tumor weight, number of metastatic lesions, and pathological changes in the tumor and lung/liver tissues. The inhibitory effect of Bruceine D on α-SMA+ CAFs activation and CAF-medicated extracellular matrix remodeling was accessed using immunohistochemistry, immunofluorescence, and Masson and Sirius Red staining. The expression levels of Notch1, Jagged1 and p-NF-κB(p65) proteins in the primary tumors were measured by immunohistochemistry and western blotting.

RESULTS

In vitro, Bruceine D significantly inhibited the migration and invasion of co-cultured CAFs and MDA-MB-231 (4T1) cells under TNF-α stimulation, reduced the expression of tumor-promoting and matrix-remodeling cytokines secreted by CAFs, and hindered the mutual activation of Notch1-Jagged1 and NF-κB(p65). In vivo, Bruceine D significantly suppressed tumor growth and the formation of lung and liver metastases by decreasing TNF-α stimulated α-SMA+ CAFs activation, collagen fibers, MMPs production, and inhibited Notch1-Jagged1/NF-κB(p65) signaling in TNBC-bearing mice.

CONCLUSION

Bruceine D effectively weakened the "tumor-CAF-inflammation" network by inhibiting the mutual activation of Notch1-Jagged1 and NF-κB(p65) and thereby suppressed TNBC metastasis. This study first explored that Bruceine D disrupted the cross-talk between CAFs and tumor cells under TNF-α stimulation to inhibit the metastasis of TNBC, and highlighted the potential of Bruceine D as therapeutic agent for suppressing tumor metastasis.

Systemic Treatment of Patients With Metastatic Breast Cancer: ASCO Resource-Stratified Guideline

PURPOSE

To guide clinicians and policymakers in three global resource-constrained settings on treating patients with metastatic breast cancer (MBC) when Maximal setting-guideline recommended treatment is unavailable.

METHODS

A multidisciplinary, multinational panel reviewed existing ASCO guidelines and conducted modified ADAPTE and formal consensus processes.

RESULTS

Four published resource-agnostic guidelines were adapted for resource-constrained settings; informing two rounds of formal consensus; recommendations received ≥75% agreement.

RECOMMENDATIONS

Clinicians should recommend treatment according to menopausal status, pathological and biomarker features when quality results are available. In first-line, for hormone receptor (HR)-positive MBC, when a non-steroidal aromatase inhibitor and CDK 4/6 inhibitor combination is unavailable, use hormonal therapy alone. For life-threatening disease, use single-agent chemotherapy or surgery for local control. For premenopausal patients, use ovarian suppression or ablation plus hormone therapy in Basic settings. For human epidermal growth factor receptor 2 (HER2)-positive MBC, if trastuzumab, pertuzumab, and chemotherapy are unavailable, use trastuzumab and chemotherapy; if unavailable, use chemotherapy. For HER2-positive, HR-positive MBC, use standard first-line therapy, or endocrine therapy if contraindications. For triple-negative MBC with unknown PD-L1 status, or if PD-L1-positive and immunotherapy unavailable, use single-agent chemotherapy. For germline BRCA1/2 mutation-positive MBC, if poly(ADP-ribose) polymerase inhibitor is unavailable, use hormonal therapy (HR-positive MBC) and chemotherapy (HR-negative MBC). In second-line, for HR-positive MBC, Enhanced setting recommendations depend on prior treatment; for Limited, use tamoxifen or chemotherapy. For HER2-positive MBC, if trastuzumab deruxtecan is unavailable, use trastuzumab emtansine; if unavailable, capecitabine and lapatinib; if unavailable, trastuzumab and/or chemotherapy (hormonal therapy alone for HR-positive MBC).Additional information is available at www.asco.org/resource-stratified-guidelines. It is ASCO's view that healthcare providers and system decision-makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Treatment and outcomes in breast cancer patients: A cross section study from the EUSOMA breast centre network

INTRODUCTION

The present study was designed to describe tumour features and treatments for patients with breast cancer. It also aimed at assessing the risk of distant metastases in relation to biological profiles, disease stages and treatment.

METHODS

Data were analysed from 81,882 patients in the EUSOMA database (disease stages at diagnosis 0-IV; median age 61 years; range 20-100 years). All patients were treated between January 2016 and December 2021 in 53 Breast Centres within the EUSOMA certification process in 13 European countries. Cases were classified as HR+ /HER2-, HR+ /HER2 + , HR-/HER2 + or HR-/HER2- and data were analysed accordingly.

RESULTS

Univariable and multivariable analyses for distant metastases were conducted on a subset of 38,119 cases with information on whether or not they had developed them. Potential determinants included sub-group type, Ki67 value, disease stage, adjuvant systemic therapies and post-operative radiation therapy. In multivariable analysis, the HR-/HER2 + and HR-/HER2- sub-groups were associated with a higher risk of distant metastases than HR+ /HER2-. Ki67 > 20 % and advanced stage disease also carried a high risk. Radiation therapy emerged as a protective factor against distant metastases.

CONCLUSIONS

Present results show a large patient database offers an information stream that can be applied to reduce uncertainties in clinical practice. Database parameters need to be updated dynamically for outcome monitoring. Molecular prognostic factors, gene-expression signatures, tumour-infiltrating lymphocytes and circulating tumoral DNA should be added.

Global Stage Distribution of Breast Cancer at Diagnosis: A Systematic Review and Meta-Analysis

Importance

Stage at diagnosis is a key prognostic factor for cancer survival.

Objective

To assess the global distribution of breast cancer stage by country, age group, calendar period, and socioeconomic status using population-based data.

Data Sources

A systematic search of MEDLINE and Web of Science databases and registry websites and gray literature was conducted for articles or reports published between January 1, 2000, and June 20, 2022.

Study Selection

Reports on stage at diagnosis for individuals with primary breast cancer (C50) from a population-based cancer registry were included.

Data Extraction and Synthesis

Study characteristics and results of eligible studies were independently extracted by 2 pairs of reviewers (J.D.B.F., A.D.A., A.M., R.S., and F.G.). Stage-specific proportions were extracted and cancer registry data quality and risk of bias were assessed. National pooled estimates were calculated for subnational or annual data sets using a hierarchical rule of the most relevant and high-quality data to avoid duplicates.

Main Outcomes and Measures

The proportion of women with breast cancer by (TNM Classification of Malignant Tumors or the Surveillance, Epidemiology, and End Results Program [SEER]) stage group.

Results

Data were available for 2.4 million women with breast cancer from 81 countries. Globally, the proportion of cases with distant metastatic breast cancer at diagnosis was high in sub-Saharan Africa, ranging from 5.6% to 30.6% and low in North America ranging from 0.0% to 6.0%. The proportion of patients diagnosed with distant metastatic disease decreased over the past 2 decades from around 3.8% to 35.8% (early 2000s) to 3.2% to 11.6% (2015 onwards), yet stabilization or slight increases were also observed. Older age and lower socioeconomic status had the largest proportion of cases diagnosed with distant metastatic stage ranging from 2.0% to 15.7% among the younger to 4.1% to 33.9% among the oldest age group, and from 1.7% to 8.3% in the least disadvantaged groups to 2.8% to 11.4% in the most disadvantaged groups.

Conclusions and Relevance

Effective policy and interventions have resulted in decreased proportions of women diagnosed with metastatic breast cancer at diagnosis in high-income countries, yet inequality persists, which needs to be addressed through increased awareness of breast cancer symptoms and early detection. Improving global coverage and quality of population-based cancer registries, including the collection of standardized stage data, is key to monitoring progress.

An Innovative Non-Linear Prediction Model for Clinical Benefit in Women with Newly Diagnosed Breast Cancer Using Baseline FDG-PET/CT and Clinical Data

Objectives: We aimed to develop a novel non-linear statistical model integrating primary tumor features on baseline [18F]-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), molecular subtype, and clinical data for treatment benefit prediction in women with newly diagnosed breast cancer using innovative statistical techniques, as opposed to conventional methodological approaches. Methods: In this single-center retrospective study, we conducted a comprehensive assessment of women newly diagnosed with breast cancer who had undergone a FDG-PET/CT scan for staging prior to treatment. Primary tumor (PT) volume, maximum and mean standardized uptake value (SUVmax and SUVmean), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were measured on PET/CT. Clinical data including clinical staging (TNM) but also PT anatomical site, histology, receptor status, proliferation index, and molecular subtype were obtained from the medical records. Overall survival (OS), progression-free survival (PFS), and clinical benefit (CB) were assessed as endpoints. A logistic generalized additive model was chosen as the statistical approach to assess the impact of all listed variables on CB. Results: 70 women with newly diagnosed breast cancer (mean age 63.3 ± 15.4 years) were included. The most common location of breast cancer was the upper outer quadrant (40.0%) in the left breast (52.9%). An invasive ductal adenocarcinoma (88.6%) with a high tumor proliferation index (mean ki-67 expression 35.1 ± 24.5%) and molecular subtype B (51.4%) was by far the most detected breast tumor. Most PTs displayed on hybrid imaging a greater volume (12.8 ± 30.4 cm3) with hypermetabolism (mean ± SD of PT maximum SUVmax, SUVmean, MTV, and TLG, respectively: 8.1 ± 7.2, 4.9 ± 4.4, 12.7 ± 30.4, and 47.4 ± 80.2). Higher PT volume (p < 0.01), SUVmax (p = 0.04), SUVmean (p = 0.03), and MTV (<0.01) significantly compromised CB. A considerable majority of patients survived throughout this period (92.8%), while five women died (7.2%). In fact, the OS was 31.7 ± 14.2 months and PFS was 30.2 ± 14.1 months. A multivariate prediction model for CB with excellent accuracy could be developed using age, body mass index (BMI), T, M, PT TLG, and PT volume as predictive parameters. PT volume and PT TLG demonstrated a significant influence on CB in lower ranges; however, beyond a specific cutoff value (respectively, 29.52 cm3 for PT volume and 161.95 cm3 for PT TLG), their impact on CB only reached negligible levels. Ultimately, the absence of distant metastasis M displayed a strong positive impact on CB far ahead of the tumor size T (standardized average estimate 0.88 vs. 0.4). Conclusions: Our results emphasized the pivotal role played by FDG-PET/CT prior to treatment in forecasting treatment outcomes in women newly diagnosed with breast cancer. Nevertheless, careful consideration is required when selecting the methodological approach, as our innovative statistical techniques unveiled non-linear influences of predictive biomarkers on treatment benefit, highlighting also the importance of early breast cancer diagnosis.

Understanding breast cancer complexity to improve patient outcomes: The St Gallen International Consensus Conference for the Primary Therapy of Individuals with Early Breast Cancer 2023

The 18th St Gallen International Breast Cancer Conference held in March 2023, in Vienna, Austria, assessed significant new findings for local and systemic therapies for early breast cancer with a focus on the evaluation of multimodal treatment options. The emergence of more effective, innovative agents in both the preoperative (primary or neoadjuvant) and post-operative (adjuvant) settings has underscored the pivotal role of a multidisciplinary approach in treatment decision making, particularly when selecting systemic therapy for an individual patient. The importance of multidisciplinary discussions regarding the clinical benefits of interventions was explicitly emphasized by the consensus panel as an integral part of developing an optimal treatment plan with the 'right' degree of intensity and duration. The panelists focused on controversies surrounding the management of common ductal/no special type and lobular breast cancer histology, which account for the vast majority of breast tumors. The expert opinion of the panelists was based on interpretations of available data, as well as current practices in their professional environments, personal and socioeconomic factors affecting patients, and cognizant of varying reimbursement and accessibility constraints around the world. The panelists strongly advocated patient participation in well-designed clinical studies whenever feasible. With these considerations in mind, the St Gallen Consensus Conference aims to offer guidance to clinicians regarding appropriate treatments for early-stage breast cancer and assist in balancing the realistic trade-offs between treatment benefit and toxicity, enabling patients and clinicians to make well-informed choices through a shared decision-making process.

Epidemiology trends and progress in breast cancer survival: earlier diagnosis, new therapeutics

PURPOSE OF REVIEW

In this review we will critically appraise the latest evidence on breast cancer (BC) survival trends and discuss how these may reflect breakthroughs in early diagnosis and treatment approaches. We will address the wide global inequalities in BC survival and review the ongoing initiatives aimed at improving cancer control worldwide.

RECENT FINDINGS

BC outcomes have improved in high-income countries during the last decades, following the implementation of strategies for early detection and optimal multimodality treatment. Novel therapeutics, such as anti-HER2 targeted treatments, have also contributed to the progress in BC survival. However, BC mortality is still high in low-income countries, due to the lack of optimal healthcare infrastructures. In the context of marked inequities in BC management across world regions, international collaborations such as the Global Breast Cancer Initiative and the Global Initiative for Cancer Registry Development work to foster capacity-building in developing countries, tackle the burden of BC and deliver the Sustainable Development Goals by 2030.

SUMMARY

Collection of robust, high-quality data from population-based cancer registries is crucial to drive and refine public health interventions. Population-based data are also the litmus paper to evaluate the real-world impact of clinical advances and monitor progress.

Role of aggressive locoregional surgery in treatment strategies for ipsilateral supraclavicular lymph node metastasis of breast cancer: a real-world cohort study

Background: Breast cancer patients with synchronous ipsilateral supraclavicular lymph node metastases (ISLNM) have unfavorable prognoses. The role of supraclavicular lymph node dissection (SLND) as a surgical intervention in the treatment of this condition remains controversial. In this study, we aimed to evaluate the prognostic factors associated with breast cancer with ISLNM and to assess the potential impact of aggressive locoregional surgical management on patient outcomes. Methods: We conducted a retrospective analysis of 250 breast cancer patients with ISLNM who were treated with curative intent at our institution between 2000 and 2020. The cohort was stratified into groups based on the extent of axillary surgery. The first group, comprising 185 patients, underwent level I/II axillary dissection. The second group, consisting of 65 patients, underwent aggressive locoregional surgery, including levels I/II/III (infraclavicular) dissection in 37 patients and levels I/II/III + SLND in 28 patients. Our study evaluated overall survival (OS) and disease-free survival (DFS) as primary endpoints, and locoregional recurrence-free survival (LRRFS) and distant metastasis-free survival (DMFS) as secondary endpoints. Results: The median follow-up time among all patients was 5.92 years (1.05-15.36 years). The 5-year OS rate was 71.89%, while the DFS rate, LRRFS rate, and DMFS rates were 59.25%, 66.38%, and 64.98%, respectively. A significant difference in OS, DFS, LRRFS, and DMFS was observed between the second group and the first group (p < 0.01). No beneficial impact on recurrence, metastasis, or survival outcomes was observed in the levels I/II/III + SLND group compared to the levels I/II/III dissection group. Multivariate logistic regression analysis revealed that levels I/II/III ± SLND surgery and T stage were associated with OS (p = 0.006 and p = 0.026), while levels I/II/III ± SLND surgery, ER+/HER2-, and histologic grade were associated with DFS (p = 0.032, p = 0.001, p = 0.032). Conclusion: Breast cancer with ISLNM may be considered a locoregional disease, requiring a combination of systemic and local therapies. Aggressive locoregional surgery has been shown to positively impact recurrence, metastasis, and survival outcomes. This approach may provide improved management of the ISLNM for breast cancer patients.

Mammography diagnosis of breast cancer screening through machine learning: a systematic review and meta-analysis

Breast cancer was the fourth leading cause of cancer-related death worldwide, and early mammography screening could decrease the breast cancer mortality. Artificial intelligence (AI)-assisted diagnose system based on machine learning (ML) methods can help improve the screening accuracy and efficacy. This study aimed to systematically review and make a meta-analysis on the diagnostic accuracy of mammography diagnosis of breast cancer through various ML methods. Springer Link, Science Direct (Elsevier), IEEE Xplore, PubMed and Web of Science were searched for relevant studies published from January 2000 to September 2021. The study was registered with the PROSPERO International Prospective Register of Systematic Reviews (protocol no. CRD42021284227). A Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used to assess the included studies, and reporting was evaluated using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The pooled summary estimates for sensitivity, specificity, the area under the receiver operating characteristic curve (AUC) for three ML methods (convolutional neural network [CNN], artificial neural network [ANN], support vector machine [SVM]) were calculated. A total of 32 studies with 23,804 images were included in the meta-analysis. The overall pooled estimate for sensitivity, specificity and AUC was 0.914 [95% CI 0.868-0.945], 0.916 [95% CI 0.873-0.945] and 0.945 for mammography diagnosis of breast cancer through three ML methods. The pooled sensitivity, specificity and AUC of CNN were 0.961 [95% CI 0.886-0.988], 0.950 [95% CI 0.924-0.967] and 0.974. The pooled sensitivity, specificity and AUC of ANN were 0.837 [95% CI 0.772-0.886], 0.894 [95% CI 0.764-0.957] and 0.881. The pooled sensitivity, specificity and AUC of SVM were 0.889 [95% CI 0.807-0.939], 0.843 [95% CI 0.724-0.916] and 0.913. Machine learning methods (especially CNN) show excellent performance in mammography diagnosis of breast cancer screening based on retrospective studies. More rigorous prospective studies are needed to evaluate the longitudinal performance of AI.

Exploring Challenges Related to Breast Cancer to Identify Opportunities for Advocacy in Hawassa City, Southern Ethiopia: A Community-Based, Qualitative Study

PURPOSE

The aim of this study was to explore breast cancer (BC) challenges to identify opportunities for advocacy in southern Ethiopia in 2022.

METHODS

Twenty-five participants from four local districts (kebeles) in Hawassa City were selected as key contributors to future work. Semistructured in-depth interviews were held for two clinicians, two local health bureau managers, two media managers, and three religious leaders. Two focus group discussions were conducted: one included six BC survivors and a caregiver; the other included two health extension workers, three members of the Women's Development Group, two community volunteers, one kebele leader, and one traditional healer.

RESULTS

To our knowledge, our study was the first time that most participants had assembled. Many referred to patients as victims and BC as a killer disease or curse. Community and religious leaders were concerned about challenges and willing to collaborate. Survivors, providers, and religious leaders were identified as key sources of information, positive messages, and leadership.

CONCLUSION

Recommendations for advocacy work in Hawassa include lobbying for BC as a health priority; including BC within the health extension package; initiating programs for earlier detection; educating the community to remove stigmas of the disease and treatments; working with media to disseminate messages that are inclusive of people in remote areas and speaking different languages; improving availability, affordability, and access to care; and assisting patients with psychosocial support. A strategic collaboration between religious leaders and health care providers was identified to increase community awareness and support advocacy for patients.

Designing clinical trials based on modern imaging and metastasis-directed treatments in patients with oligometastatic breast cancer: a consensus recommendation from the EORTC Imaging and Breast Cancer Groups

Breast cancer remains the most common cause of cancer death among women. Despite its considerable histological and molecular heterogeneity, those characteristics are not distinguished in most definitions of oligometastatic disease and clinical trials of oligometastatic breast cancer. After an exhaustive review of the literature covering all aspects of oligometastatic breast cancer, 35 experts from the European Organisation for Research and Treatment of Cancer Imaging and Breast Cancer Groups elaborated a Delphi questionnaire aimed at offering consensus recommendations, including oligometastatic breast cancer definition, optimal diagnostic pathways, and clinical trials required to evaluate the effect of diagnostic imaging strategies and metastasis-directed therapies. The main recommendations are the introduction of modern imaging methods in metastatic screening for an earlier diagnosis of oligometastatic breast cancer and the development of prospective trials also considering the histological and molecular complexity of breast cancer. Strategies for the randomisation of imaging methods and therapeutic approaches in different subsets of patients are also addressed.

Crosstalk between ferroptosis and steroid hormone signaling in gynecologic cancers

Ferroptosis is a novel types of regulated cell death and is widely studied in cancers and many other diseases in recent years. It is characterized by iron accumulation and intense lipid peroxidation that ultimately inducing oxidative damage. So far, signaling pathways related to ferroptosis are involved in all aspects of determining cell fate, including oxidative phosphorylation, metal-ion transport, energy metabolism and cholesterol synthesis progress, et al. Recently, accumulated studies have demonstrated that ferroptosis is associated with gynecological oncology related to steroid hormone signaling. This review trends to summarize the mechanisms and applications of ferroptosis in cancers related to estrogen and progesterone, which is expected to provide a theoretical basis for the prevention and treatment of gynecologic cancers.

Breast cancer survival in Mexico between 2007 and 2016 in women without social security: a retrospective cohort study

Background

Essential indicators of health system performance for breast cancer are lacking in Mexico. We estimated survival and clinical stage distribution for women without social insurance who were treated under a health financing scheme that covered 60% of the Mexican population.

Methods

We conducted a retrospective cohort study cross-linking reimbursement claims for 56,847 women treated for breast cancer between 2007 and 2016 to a mortality registry. We estimated overall- and clinical stage-specific survival and breast cancer survival according to patient age, state of residence, marginalization, type of treatment facility, and patient volume of the treatment facility. We also explored the distribution of clinical stage according to age, year of treatment initiation, and state where the woman was treated. We used log-rank tests and estimated 95% CIs to compare differences between patient groups.

Findings

Median age was 52 years (interquartile range [IQR] 45, 61) (Sixty five percent patients (36,731/56,847) had advanced disease at treatment initiation. Five-year overall survival was 72.2% (95% CI 71.7, 72.6). For early disease (excluding stage 0), 5-year overall survival was 89.0% (95% CI 88.4, 89.5), for locally advanced disease 69.9% (95% CI 69.0, 70.2) and for metastatic 36.9% (95% CI 35.4, 38.4). Clinical stage at treatment initiation and breast cancer survival remained unchanged in the period analyzed. Clinical stage and survival differed across age groups, state of residence, and type of facility where women received treatment.

Interpretation

In the absence of population-based cancer registries, medical claims data may be efficiently leveraged to estimate essential cancer-related performance indicators.

Funding

The authors received no financial support for this research.

European Society of Breast Cancer Specialists/Advanced Breast Cancer Global Alliance quality indicators for metastatic breast cancer care

AIMS

Improvement in the care of patients with metastatic breast cancer (MBC) can only occur if the adequate quality of care is implemented and verified, including access to multidisciplinary, specialised care given in accordance with high-quality guidelines. To this purpose, European Society of Breast Cancer Specialists and the Advanced Breast Cancer Global Alliance joined efforts to develop the first set of quality indicators (QI) specifically for MBC that should be routinely measured and evaluated to ensure that breast cancer centres meet the required standards.

METHODS

A working group of multidisciplinary European experts in breast cancer met to discuss each identified QI, reporting the definition, the minimum and target standard for breast cancer centres to achieve, and the motivation for selection. The level of evidence was determined according to the short version of the United States Agency for Healthcare Research and Quality classification.

RESULTS

QI to measure access to and involvement in multidisciplinary and supportive care, appropriate pathological characterisation of disease, systemic therapies and radiotherapy were developed with the consensus of the working group.

CONCLUSIONS

This is the first effort of a multistep project that aims to have QI for MBC routinely measured and evaluated to ensure that breast cancer centres achieve mandated standards in the care of patients with metastatic disease.

Artificial intelligence-assisted ultrasound image analysis to discriminate early breast cancer in Chinese population: a retrospective, multicentre, cohort study

Background

Early diagnosis of breast cancer has always been a difficult clinical challenge. We developed a deep-learning model EDL-BC to discriminate early breast cancer with ultrasound (US) benign findings. This study aimed to investigate how the EDL-BC model could help radiologists improve the detection rate of early breast cancer while reducing misdiagnosis.

Methods

In this retrospective, multicentre cohort study, we developed an ensemble deep learning model called EDL-BC based on deep convolutional neural networks. The EDL-BC model was trained and internally validated on B-mode and color Doppler US image of 7955 lesions from 6795 patients between January 1, 2015 and December 31, 2021 in the First Affiliated Hospital of Army Medical University (SW), Chongqing, China. The model was assessed by internal and external validations, and outperformed radiologists. The model performance was validated in two independent external validation cohorts included 448 lesions from 391 patients between January 1 to December 31, 2021 in the Tangshan People's Hospital (TS), Chongqing, China, and 245 lesions from 235 patients between January 1 to December 31, 2021 in the Dazu People's Hospital (DZ), Chongqing, China. All lesions in the training and total validation cohort were US benign findings during screening and biopsy-confirmed malignant, benign, and benign with 3-year follow-up records. Six radiologists performed the clinical diagnostic performance of EDL-BC, and six radiologists independently reviewed the retrospective datasets on a web-based rating platform.

Findings

The area under the receiver operating characteristic curve (AUC) of the internal validation cohort and two independent external validation cohorts for EDL-BC was 0.950 (95% confidence interval [CI]: 0.909-0.969), 0.956 (95% [CI]: 0.939-0.971), and 0.907 (95% [CI]: 0.877-0.938), respectively. The sensitivity values were 94.4% (95% [CI]: 72.7%-99.9%), 100% (95% [CI]: 69.2%-100%), and 80% (95% [CI]: 28.4%-99.5%), respectively, at 0.76. The AUC for accurate diagnosis of EDL-BC (0.945 [95% [CI]: 0.933-0.965]) and radiologists with artificial intelligence (AI) assistance (0.899 [95% [CI]: 0.883-0.913]) was significantly higher than that of the radiologists without AI assistance (0.716 [95% [CI]: 0.693-0.738]; p < 0.0001). Furthermore, there were no significant differences between the EDL-BC model and radiologists with AI assistance (p = 0.099).

Interpretation

EDL-BC can identify subtle but informative elements on US images of breast lesions and can significantly improve radiologists' diagnostic performance for identifying patients with early breast cancer and benefiting the clinical practice.

Funding

The National Key R&D Program of China.

Socioeconomic inequalities in cancer mortality between and within countries in Europe: a population-based study

Background

Reducing socioeconomic inequalities in cancer is a priority for the public health agenda. A systematic assessment and benchmarking of socioeconomic inequalities in cancer across many countries and over time in Europe is not yet available.

Methods

Census-linked, whole-of-population cancer-specific mortality data by socioeconomic position, as measured by education level, and sex were collected, harmonized, analysed, and compared across 18 countries during 1990-2015, in adults aged 40-79. We computed absolute and relative educational inequalities; temporal trends using estimated-annual-percentage-changes; the share of cancer mortality linked to educational inequalities.

Findings

Everywhere in Europe, lower-educated individuals have higher mortality rates for nearly all cancer-types relative to their more highly-educated counterparts, particularly for tobacco/infection-related cancers [relative risk of lung cancer mortality for lower- versus higher-educated = 2.4 (95% confidence intervals: 2.1-2.8) among men; = 1.8 (95% confidence intervals: 1.5-2.1) among women]. However, the magnitude of inequalities varies greatly by country and over time, predominantly due to differences in cancer mortality among lower-educated groups, as for many cancer-types higher-educated have more similar (and lower) rates, irrespective of the country. Inequalities were generally greater in Baltic/Central/East-Europe and smaller in South-Europe, although among women large and rising inequalities were found in North-Europe (relative risk of all cancer mortality for lower- versus higher-educated ≥1.4 in Denmark, Norway, Sweden, Finland and the England/Wales). Among men, rate differences (per 100,000 person-years) in total-cancer mortality for lower-vs-higher-educated groups ranged from 110 (Sweden) to 559 (Czech Republic); among women from approximately null (Slovenia, Italy, Spain) to 176 (Denmark). Lung cancer was the largest contributor to inequalities in total-cancer mortality (between-country range: men, 29-61%; women, 10-56%). 32% of cancer deaths in men and 16% in women (but up to 46% and 24%, respectively in Baltic/Central/East-Europe) were associated with educational inequalities.

Interpretation

Cancer mortality in Europe is largely driven by levels and trends of cancer mortality rates in lower-education groups. Even Nordic-countries, with a long-established tradition of equitable welfare and social justice policies, witness increases in cancer inequalities among women. These results call for a systematic measurement, monitoring and action upon the remarkable socioeconomic inequalities in cancer existing in Europe.

Funding

This study was done as part of the LIFEPATH project, which has received financial support from the European Commission (Horizon 2020 grant number 633666), and the DEMETRIQ project, which received support from the European Commission (grant numbers FP7-CP-FP and 278511). SV and WN were supported by the French Institut National du Cancer (INCa) (Grant number 2018-116). PM was supported by the Academy of Finland (#308247, # 345219) and the European Research Council under the European Union's Horizon 2020 research and innovation programme (grant agreement No 101019329). The work by Mall Leinsalu was supported by the Estonian Research Council (grant PRG722).

Financial Toxicity Among Patients With Breast Cancer Worldwide: A Systematic Review and Meta-analysis

Importance

Financial toxicity (FT) is the negative impact of cost of care on financial well-being. Patients with breast cancer are at risk for incurring high out-of-pocket costs given the long-term need for multidisciplinary care and expensive treatments.

Objective

To quantify the FT rate of patients with breast cancer and identify particularly vulnerable patient populations nationally and internationally.

Data Sources

A systematic review and meta-analysis were conducted. Four databases-Embase, PubMed, Global Index Medicus, and Global Health (EBSCO)-were queried from inception to February 2021. Data analysis was performed from March to December 2022.

Study Selection

A comprehensive database search was performed for full-text, English-language articles reporting FT among patients with breast cancer. Two independent reviewers conducted study screening and selection; 462 articles underwent full-text review.

Data Extraction and Synthesis

A standardized data extraction tool was developed and validated by 2 independent authors; study quality was also assessed. Variables assessed included race, income, insurance status, education status, employment, urban or rural status, and cancer stage and treatment. Pooled estimates of FT rates and their 95% CIs were obtained using the random-effects model.

Main Outcomes and Measures

FT was the primary outcome and was evaluated using quantitative FT measures, including rate of patients experiencing FT, and qualitative FT measures, including patient-reported outcome measures or patient-reported severity and interviews. The rates of patients in high-income, middle-income, and low-income countries who incurred FT according to out-of-pocket cost, income, or patient-reported impact of expenditures during breast cancer diagnosis and treatment were reported as a meta-analysis.

Results

Of the 11 086 articles retrieved, 34 were included in the study. Most studies were from high-income countries (24 studies), and the rest were from low- and middle-income countries (10 studies). The sample size of included studies ranged from 5 to 2445 people. There was significant heterogeneity in the definition of FT. FT rate was pooled from 18 articles. The pooled FT rate was 35.3% (95% CI, 27.3%-44.4%) in high-income countries and 78.8% (95% CI, 60.4%-90.0%) in low- and middle-income countries.

Conclusions and Relevance

Substantial FT is associated with breast cancer treatment worldwide. Although the FT rate was higher in low- and middle-income countries, more than 30% of patients in high-income countries also incurred FT. Policies designed to offset the burden of direct medical and nonmedical costs are required to improve the financial health of vulnerable patients with breast cancer.

A scoping review of natural language processing of radiology reports in breast cancer

Various natural language processing (NLP) algorithms have been applied in the literature to analyze radiology reports pertaining to the diagnosis and subsequent care of cancer patients. Applications of this technology include cohort selection for clinical trials, population of large-scale data registries, and quality improvement in radiology workflows including mammography screening. This scoping review is the first to examine such applications in the specific context of breast cancer. Out of 210 identified articles initially, 44 met our inclusion criteria for this review. Extracted data elements included both clinical and technical details of studies that developed or evaluated NLP algorithms applied to free-text radiology reports of breast cancer. Our review illustrates an emphasis on applications in diagnostic and screening processes over treatment or therapeutic applications and describes growth in deep learning and transfer learning approaches in recent years, although rule-based approaches continue to be useful. Furthermore, we observe increased efforts in code and software sharing but not with data sharing.

Screening Programs for Breast Cancer: Toward Individualized, Risk-Adapted Strategies of Early Detection

Early detection of breast cancer (BC) comprises two approaches: screening of asymptomatic women in a specified target population at risk (usually a target age range for women at average risk), and early diagnosis for women with BC signs and symptoms. Screening for BC is a key health intervention for early detection. While population-based screening programs have been implemented for age-selected women, the pivotal clinical trials have not addressed the global utility nor the improvement of screening performance by utilizing more refined parameters for patient eligibility, such as individualized risk stratification. In addition, with the exception of the subset of women known to carry germline pathogenetic mutations in (high- or moderately-penetrant) cancer predisposition genes, such as BRCA1 and BRCA2, there has been less success in outreach and service provision for the unaffected relatives of women found to carry a high-risk mutation (i.e., "cascade testing") as it is in these individuals for whom such actionable information can result in cancers (and/or cancer deaths) being averted. Moreover, even in the absence of clinical cancer genetics services, as is the case for the immediate and at least near-term in most countries globally, the capacity to stratify the risk of an individual to develop BC has existed for many years, is available for free online at various sites/platforms, and is increasingly being validated for non-Caucasian populations. Ultimately, a precision approach to BC screening is largely missing. In the present chapter, we aim to address the concept of risk-adapted screening of BC, in multiple facets, and understand if there is a value in the implementation of adapted screening strategies in selected women, outside the established screening prescriptions, in the terms of age-range, screening modality and schedules of imaging.